Transcript Staff Safety Assessment

CSTS: The Cardiovascular Surgical Translational Study
Senior Leadership of Quality and Safety
Initiatives in Health Care
Peter J. Pronovost, MD, PhD
The Armstrong Institute for Patient Safety
and Quality
Learning Objectives
• To understand the differences between technical
and adaptive work
• To understand the role of senior leaders in
addressing both types of work in QI efforts
• To share tactics used successfully by senior
executives and leaders to support QI
Goals
• Initially work to eliminate central line associated
blood stream infections (CLABSI); state mean <
1/10000 catheter days, median 0, (then Surgical Site
Infections, and finally Ventilator Associated
Pneumonia).
• To improve safety culture by 50%
• To learn from one defect per month
• To increase Executive participation in your quality
and safety activites.
Safety Score Card
Keystone ICU Safety Dashboard
2004
2006
How often did we harm (BSI) (median)
2.8/1000
0
How often do we do what we should
66%
95%
How often did we learn from mistakes*
100s
100s
Have we created a safe culture
% Needs improvement in
Safety climate*
Teamwork climate*
84%
82%
43%
42%
CUSP is intervention to improve these*
Technical Work
• Addresses problems for which the definition is clear,
the potential solutions are reasonably clear, and
usually require little or minimal learning
• Responsibility for implementing a solution is
reasonably clear between leaders and followers.
Leadership Without Easy Answers
(Heifetz, 1994)
• Leadership is
“activity to mobilize adaptive work” (p. 27).
Adaptive Work
• Addresses problems that require a change in
attitudes, beliefs, and behaviors
• Involves shared responsibility for change: leaders
share responsibility with organizational staff and key
stakeholders.
Most Common Leadership Error
• Treating an adaptive problem as technical
The Work of Adaptive Change
• Determining the direction – what must change
•
Determining the methods - how to change
Leading Change
Senior
leaders
Team
leaders
Staff
Engage
How does this make the world a better place?
Educate
What do we need to know?
adaptive
technical
Execute
adaptive
Evaluate
technical
What do we need to do?
How can we do it with my resources and
culture?
How do we know we improved safety?
Pronovost: Health Services Research 2006
Leading Change
•
Is everyone clear on the goals, timelines, and mission?
•
Is the necessary structure in place – people, roles,
authority and responsibility?
•
Are decision making, problem solving and conflict
management processes clear?
•
Are material resources in place – space, equipment,
people, budgets (Senior Executive can help)?
•
Are financial tracking mechanisms in place (CMS P4P
implications)
Action Items for Senior Leaders
1.
Make certain an executive is assigned to each unit and
meets regularly as a member of the project team .
–
let the staff know senior executives are invested and
will work as hard as they do to make it a success.
2.
Set clear project goals and expectations for the leaders
and staff in critical care units.
–
Provide opportunities for project teams to meet with
senior executives and the board to discuss the project
3.
Provide the necessary resources – time to work on the
Project, funds for travel, training, equipment, supplies, etc.
Action Items for Senior Leaders
3. Support transparent communication with everyone
–
BSI rates
–
SSI rates
–
VAP rates
–
Process barriers and successes
–
Tell your own Josie Story; publically discuss a patient
who suffered preventable harm at your
organization
4. Expect resistance and be prepared to address it
effectively
5. Celebrate wins and provide encouragement, support,
attention, and resources if there are set backs.
CSTS: The Cardiovascular Surgical Translational Study
Staff Safety Assessment
Elizabeth Martinez, MD, MHS
Massachusetts General Hospital
Harvard University
CSTS Content Call
Learning Objectives
• To understand Step 2 of CUSP: Identify Defects
• To understand how to Implement the Staff
Safety Assessment
• To understand ways to use results of the Staff
Safety Assessment
Goals
• To identify defects
• To leverage the wisdom of the front line worker
• To prepare a list of improvement opportunities that
has face validity and provides a focus for local
CUSP activities.
Comprehensive Unit-Based Safety Program:
CUSP
CUSP
CLABSI
1.
Educate staff on science of safety
1. Remove Unnecessary Lines
2.
Identify defects
2. Wash Hands Prior to Procedure
3.
Assign executive to adopt unit
3. Use Maximal Barrier Precautions
4.
Learn from one defect per quarter
4. Clean Skin with Chlorhexidine
5.
Implement teamwork tools
5. Avoid Femoral Lines
The CUSP Team
The smaller group that spreads the
intervention
to the rest of the unit
Education and engagement activities in
each clinical area
• BSI: Providing Evidence, Modeling the line
placement steps; stopping insertions that violate
protocol; having one-on-one talks where
necessary;
• Facilitating CUSP Activities
6
Comprehensive Unit-based Safety
Program (CUSP)
1.
Educate staff on science of safety
(www.safercare.net)
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from one defect per quarter
5.
We are here
Implement teamwork tools
You are here!!!
7
Martinez E,,Thompson D. Anesth Analg 2011;112:1061-74
Identify Defects
• Review error reports, liability claims, sentinel events
or M&M conference
• Ask staff how the next patient will be harmed
Transparency
Making project and progress visible
to everyone
How are We Going to Harm the Next
Patient?
One way to make harm visible-- get staff
thinking and talking about safety and how to
improve it
Step 2: Staff Identify Defects
Frontline caregivers are the eyes and ears of patient safety
• Identify clinical or operational problems that negatively
impact patient safety (have or could)
• Use the Staff Safety Assessment tool
– How will the next patient be harmed in our unit
– What can be done to minimize patient harm or prevent this safety hazard
• Clinical area managers and CUSP team review suggestions,
set the agenda for discussion with executive partner
Appendix C
STAFF SAFETY ASSESSMENT – CUSP
Purpose of this form: The purpose of this form is to tap into your knowledge and experiences
at the frontlines of patient care to find out what risks are present on your unit that have or could
jeopardize patient safety.
Who should complete this form: All health care providers.
How to complete this form: Provide as much detail as possible when answering the 2
questions. Drop off your completed safety assessment form in the location designated by the
CUSP improvement team with your job category, date and unit in the top box (name is
optional).
When to complete this form: Assessing safety should be considered an iterative process with
no defined end (like a moving bicycle wheel). Thus, it can be filled out by any health care
provider at any time. At the very least, all health care providers should complete this form
semiannually.
Name (optional):
Job Category:
Date:
Unit:
Please describe how you think the next patient in your unit/clinical area will be harmed.
Please describe what you think can be done to prevent or minimize this harm.
Thank you for helping improve safety in your workplace!
Step 2: Staff Identify Defects
• What Team Leaders need to do:
• Hand out a Staff Safety Assessment form to all staff, clinical
and non-clinical, in the unit
• Establish a collection box or envelope
• Identify and group common defects (such as communication,
medications, patient falls, supplies, etc.)
• Summarize as frequencies (i.e., what percent of responses
were for communication)
Prioritize Defects
• List all defects
• Discuss with staff what are the three greatest risks
Step 2: Staff Identify Defects
• Report the identified defects to staff, executive
partner
• ICU managers and CUSP team prioritize defects
identified by the potential level of risk to the patient
• Select one to work on with support of Executive
• Step 2 should be ongoing
Appendix D
SAFETY ISSUES WORKSHEET FOR SENIOR EXECUTIVE PARTNERSHIP - CUSP
Date of Safety Rounds:
Unit:
Attendees:
1.
2.
3.
4.
5.
6.
7.
8.
9.
(use back of form for additional attendees)
Identified Issue
Potential/Recommended
Solution
Resources
Needed
Not
Needed
1.
2.
3.
4.
5.
6.
7.
8.
9.
Copy form if more than 9 safety issues are identified.
Please return this form to your project leader
Appendix E
STATUS OF SAFETY ISSUES – CUSP
Unit: ___________________________________________
Date
Safety Issue
New and Ongoing
Contact
Status
Goal
Date
Safety Issue
Completed
Contact
Status
Goal
Please return this form to your project leader
CUSP Team activitieskeeping on track
• Team meetings (recommend monthly)
• Review of data
(monthly)
• Meet w/ Exec Partner (monthly or more)
• Executive review of data (monthly)
• Presentations to hospital colleagues
–
(leadership, frontline staff, board)
Comprehensive Unit-based Safety
Program (CUSP)
1.
Educate staff on science of safety
(www.safercare.net)
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from one defect per quarter
5.
We are here
Implement teamwork tools
You are here!!!
Action Items
1. Educate staff on science of safety
1. Distribute staff safety assessment to ALL members
of CV teams
–
Identity location for these to be returned anonymously –
and in an ongoing fashion
2. Summarize the data
3. Review with CUSP team and senior executive to
prioritize next steps